Predictors of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease
Authors: Lee H. Schwamm, Hooman Kamel, Christopher B. Granger, Jonathan P. Piccini, Jeffrey M. Katz, Pramod P. Sethi, Evgeny V. Sidorov, Scott E. Kasner, Scott B. Silverman, Theodore T. Merriam, Noreli Franco, Paul D. Ziegler, Richard A. Bernstein, Freddy Abi-Samra, Indrani Acosta, Ali Al Balushi, Ahmad Al-Awwad, Rizwan Alimohammad, Moayd Alkahalifah, James Allred, Mohammad Alsorogi, Valerie Arias, Sushanth Aroor, Rohan Arora, Negar Asdaghi, Khaled Asi, Manish Assar, Nitish Badhwar, Javier Banchs, Sandeep Bansal, Conor Barrett, Bahar Beaver, Stuart Beldner, Gary Belt, Matthew Bernabei, Michael Bernard, Nirav Bhatt, James Black, Don Bledsoe, Heather Bonaguidi, Kay Bonyak, Clara Boyd, Christian Cajavilca, Frances Caprio, Jacqueline Carter, Breehan Chancellor, Cherylee Chang, Gauhar Chaudhary, Shuchi Chaudhary, Peter Cheung, Marilou Ching, Larry Chinitz, David Chiu, Himanshu Chokhawala, Indrajit Choudhuri, Subbarao Choudry, Stephen Clayton, Jonathan Cross, Brett Cucchiara, Andre Culpepper, James Daniels, Subasini Dash, Victor Del Brutto, Christopher Deline, Claire Delpirou Nouh, Rajat Deo, Mandip Dhamoon, George Dillon, Alan Donsky, Amit Doshi, Amanda Downey, Srinivas Dukkipati, Laurence Epstein, Mark Etherton, Michael Fara, Pierre B Fayad, Robert Felberg, Murray Flaster, David Frankel, Steve Furer, Rajan Gadhia, Paul Gadient, Paul Garabelli, Douglas Gibson, Taya Glotzer, Davida Goltz, David Gordon, Sarah Graner, Dion Graybeal, Maranda Randi Grimes, Waldo Guerrero, John Hanna, Qing Hao, Sanjeev Hasabnis, Rashedul Hasan, E Kevin Heist, Deborah Horowitz, J Maurice Hourihane, Haitham Hussein, Koto Ishida, Haisam Ismail, Ram Jadonath, Sameer Jamal, Pradipkumar Jamnadas, Judy Jia, Mark Johnson, Richard Jung, Mary Kalafut, Junaid Kalia, Amit Kandel, Scott Kasner, Larry Katz, Jeffrey Katz, Gurmeen Kaur, Michelle Kearney, Samuel Khatib, Susan Kim, Chee Kim, Joseph Kipta, Sebastian Koch, Jacob Koruth, Howard Kreger, Kristopher Krueger, Christeena Kurian, Eugene LaFranchise, Litsa Lambrakos, Marie-Noelle Langan, Randall Lee, Richard Libman, Kaitlyn Lillemoe, William Logan, Aaron Lord, Steven Lubitz, Jeanie Luciano, Jennifer Lynch, Paul C Maccaro, Alejandro Magadan, Rakesh Magun, Maheen Malik, Amer Malik, Sushma Manda, Erika Marulanda-Londono, Ivan Matos Diaz, Beth Mattera, Angela McCall-Brown, Nancy Mcclelland, Karl Meisel, Zeeshan Memon, Scott Mendelson, Ivan Mendoza, Theodore Merriam, Steven Messe, William M Miles, Marc Miller, Osman Mir, Raul Mitrani, Daniel Morin, Kent Morris, Mohammad Moussavi, Ashkan Mowla, Stacy Moye, Michael Mullen, Savannah Mullins, Karah Neisen, Claude Nguyen, Imran Niazi, Nicholas Olson, Gregory Olsovsky, Gustavo Ortiz, Matthew Ostrander, Aneesh Pakala, Brett Parker, Mary Parker, Rod Passman, Anand Patel, Apoor Patel, Robert Andrew (Drew) Pickett, Glenn Polin, Glauco Radoslovich, Jose Ramano, Tapan Rami, Darwin Ramirez, Jennifer Rasmussen, Bappaditya Ray, Vivek Reddy, Ramakota Reddy, Russell Reeves, Robert Regenhardt, David Rempe, Paul Rogers, John Rogers, Steven Rowe, Chris Rowley, Ilana Ruff, Matthew Sackett, Rehan Sajjad, Rony Salem, Marc Saltzman, Pasquale Santangeli, Scott Saucedo, Robert Sawyer, Robert Schaller, Susan Seeger, Pramod Sethi, Ty Shang, Jitendra Sharma, Richa Sharma, Kara Sheinart, Gunjan Shukla, Jeffrey Shultz, Evgeny Sidorov, Scott Silverman, Jay Simonson, David Singh, Elaine Skalabrin, Kelly Sloane, Macey Smith, Wade Smith, Diane Soik, Stavros Stavrakis, Laura Stein, Jonathan S Steinberg, Nicole Sur, Donald Switzer, Nadeem Talpur, Aaron Tansy, Kristi Tempro, Varoon Thavapalan, Abraham Thomas, Kevin Thomas, Jose Torres, Luis Torres, Stanley Tuhrim, Poulina Uddin, Gabriel Vidal, Anand Viswanathan, John Volpi, Kathleen Ward, Jesse Weinberger, William Whang, Michael Wilder, Jonathan Willner, Paul Wright, Qingyang Yuan, Cen Zhang, Dennis Zhu, Kenneth Zide, John Zimmerman, Richard Zweifler
Journal: JAMA Neurology (2022)

The Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care.To determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM.This was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022.ICM monitoring vs site-specific usual care (short-duration external cardiac monitoring).The ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values <.10. AF detection rates were calculated using Kaplan-Meier survival estimates.The analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean [SD] age, 66.6 [9.3] years; 144 men [60.0%]; 96 [40.0%] women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio [HR], 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P < .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P < .001).Among patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance.ClinicalTrials.gov Identifier: NCT02700945.